Limited Use Note(s)
PETROLATUM/MINERAL OIL
55% & 42.5% Oph Oint-3.5g Pk
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Reason For Use Code
Clinical Criteria
49
For patients with objective evidence of keratoconjunctivitis sicca as confirmed by filamentary keratopathy on slit lamp examination or biopsy.
LU Authorization Period: Indefinite
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